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I enjoyed this podcast. As a primary care physician who has practiced medicine for 25 years and who has raised 3 children, I've had a good overview on this issue. I actually did appreciate Calley's point that the medical "establishment", particularly some of the highly respected and influential medical centers and individual physicians, need to speak more loudly about this public health crisis. I think the 2 key changes that have occurred starting in the early 80s is the overwhelm of our food system with sugar and processed carbs (HIGHLY PALATABLE FOODS) AND the whole concept of SNACKING. As I was growing up in the 60's/70's, snacking was not the mainstay and commonplace daily habit that it is now. I always appreciate VP's point of view, but I don't think our more sedentary lifestyle has nearly as much impact as the bad food choices American culture currently encourages. (exercise is fantastic, a cornerstone of good health - but doesn't drive weight to the same extent that types of food and the schedule on which we eat them does.)

Most preschools and early elementary schools mandate that mother's help provide "snacks" for the kids' classes - because no way should young kids survive from breakfast all the way to lunch without a "snack". Most Americans feel no hesitation to eat whenever they feel hungry - and often eat/snack without fully realizing it. The lure of highly palatable foods is greater than most of us can fully resist. "Big food" companies have teams of researchers who understand the "bliss point" and the exact balance of salty/cheesy/melt-in-your mouth taste that hooks the human brain. Our "drive through" culture only fuels this fire - drive through fast food whenever we want it. I am frequently shocked by the family's that allow their children to develop "Starbucks habits" - besides the calories easily hidden in these drinks, how do they afford it. Why allow your child to develop this expensive habit? Youth sports even focuses around food - so easy for parents to drive through fast food on the way to or following practice; games are celebrated with eating out at high-calorie restaurants, team travel has a total focus on eating out/snacks/etc. Even these kids who are moving quite a bit are having these bad food practices cemented in their brain as an OK way to live.

Probably our best societal move would be to look at highly palatable and processed food choices in the same way that we evaluate what sorts of things have helped decrease smoking - clear public warnings by health officials on a constant basis about how bad these things are for you; tax/pricing these foods to a level it becomes uncomfortable, etc. Much of our focus should be on early childhood - we need strong messaging to families with young children that snacking and sugar/processed foods are not healthy.

I think we need to use Ozempic (or Wegovy) as a "tool" to help some people who have significant health issues due to weight. it doesn't work for everyone and it is certainly NOT the "answer" to childhood obesity. And sure, genetics has some part in this, but not to the extent that exactly what and when we eat does. For medical doctors to tell anyone that this is not directly related to what and when you eat, is irresponsible and disempowering. Obesity certainly is a "brain thing" - but it is our human brains reacting to diets high in sugar/processed foods and too much of it throughout the day. And yes, the longer you are overweight/obese, the more your brain chemistry becomes focused on keeping you there, but it is not insurmountable and Ozempic is not the national "answer".

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The obesity epidemic is most of all an epidemic brought on by highly processed, unhealthy food that is more available and cheaper than healthy food - and it is food engineered to be addictive. So now we're going to provide expensive big pharma medicines to counteract the obesity caused by corporate control of food abetted by government subsidies.

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My priors would have been to Calley's point of view. But the constant stream of what seemed like combative adhominems, the radical simplification of saying there's only one solution with only one cause, and implying his point of view is the only obvious one, all made me less sympathetic to his point of view. I was disappointed with Bari's management of this conversation.

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Callie is understandably angry. The bottom line is most people don't care enough to look at their diet and lifestyle and demand better food and lifestyles from our leaders. The system is set up to keep us sick and dependent on drugs. I work in Pathology I see diet/lifestyle diseases everyday we have 5 years olds with fatty liver. Our priorities are not align with health

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It seems counterintuitive to me that the doctor on 20/20 said obesity is a brain issue, caused by genetics and has nothing to do with how much a person eats. But doesn’t this drug work by suppressing appetite. So if this drug stops a person from overeating, than doesn’t it mean that the cause of obesity is overeating and not genetics?

Also, the 85% probability that child who has obese parents will also be obese doesn’t prove that it’s genetic. It is just a correlation not necessarily a causation. It seems obvious to me that a child growing up in environment where the parents over eat and are sedentary will more likely also overeat and be sedentary.

The one thing I wish they would have talked more about is the new social rules about body positivity and how that affects the health care system. Are doctors, especially pediatricians even allowed to discuss a patient’s weight anymore or would that be considered fat shaming? With this new culture, embracing any size, how can we even begin to talk about, much less change regulations if we are not allowed to talk about it?

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As a non-American subscriber, one thing that struck me about the podcast was how Americans (I live in Australia) seem completely blind to the fact that there is something very wrong with the food culture in America. What counts as “food” includes things like pop tarts and twinkies (which I saw for the first time when I visited the US in 1995) and I recall being shocked in the supermarket because the only available bread was soft and sweet and all the cheese was bright orange. When I first arrived I couldnt figure out how to even buy what I considered normal food - unsweetened, unprocessed bread and dairy. Then portion sizes were at least twice as big as what I was used to, fast food was ubiquitous and people ate it as an a normal meal for lunch, maybe even every day, and the menus of “family” restaurants were wall to wall fried and sweetened food with each plate enough to feed several people. I had been raised to consider McDonalds a treat, and not actually real food. Like having chocolate cake for dinner. We could have it very occasionally but it was not a genuine meal.

I say this only because I don’t know how you turn this around. It takes generations to create a culture around food - what is a normal amount to eat, and what food even is. Are insects food? Pigs? Nettles? Dogs? Our culture tells us. From the outside it seems like a good part of America’s problem with obesity is not so much genes as a deeply unhealthy concept of eating taught to children, generation after generation and reinforced by what is available to eat and what people are conditioned to consider normal. The American diet it literally hard to stomach for people coming from outside the culture and yet those within it must struggle to gain that perspective.

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Give them hell Callie - follow the money folks - metabolic health is mental health - this is just another quick fix for folks who don't want to stop eating processed crap, sugar, seed oils and grains

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Speaking as someone with an addiction background, I do find the framing of food as being an addiction compelling. However, that suggests to me that perhaps the most ingenuous interpretation of Ozempic (and similar medications) would be analogous to medication-assisted treatment for opioid addiction, in which people receive substitute opioid medications (Suboxone, methadone), which are less dangerous than recreational drugs but which sate cravings. However, this approach is part of a comprehensive treatment model which includes a lot of nonmedical strategies to help people get their lives back on track.

In the obesity space, I think one can clearly analogize that a medication may help sate cravings for food and may enable change, but the medication is not itself the change.

In both cases, medicine can be practiced well or poorly. I found Calley's characterization of the worst-case scenario unpersuasive in the sense that it ignores the possibility of integrated care.

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I listened with interest to this, and it turned out to be a really worthwhile discussion, although one which occasionally devolved into a somewhat frustrating shit-show. Please indulge me:

1. Calley Means is generally correct about nearly everything he asserted about the science and of metabolic syndrome and dysfunction, but he doesn't have the public relations game that Drs. Anekwe and Prasad do. I would argue that Means's sister, Dr Casey Means does indeed have the professional demeanor as well as the medical chops to argue all the factual information Calley wanted to communicate without sounding combative and rhetorical. Dr Casey Means is an effective, measured communicator of metabolic health issues and facts, and I wish we could have had her as part of this discussion. Furthermore, either she or someone like Dr David Perlmutter could argue better why a pharmaceutical intervention like Ozempic isn't going to necessarily make actual long-term health outcomes better, as Ozempic is treating a symptom of a lagging indicator of dysfunction, which it doesn't cure.

2. Dr Anekwe was a mixed bag. On the one hand, I respected her professionalism and composure, particularly in the face of criticism. And I truly believe she and her fellow clinicians believe in their mission. But she was unable to ever say effectively that the reason why recommending that good diet and exercise "doesn't always work" is that (1) there is so much more education about food and nutrition required to make a change in most people's lives, especially when the facts often run against cultural and community norms, and (2) she did not acknowledge something that just about *anyone* who is into health and nutrition knows: What normie establishment medicine thinks is a good recommendation for diet might be 10-30 years behind the times, and she never explained what those dietary recommendations were, which may be what we now know to be bad recommendations. The idea that an obesity clinic doctor (was it her colleague, quoted at the beginning of the podcast?) would say of an obese patient, "She exercises 5-6 times a week to no avail," is redolent of the 90's calling and wanting their health advice back, and it makes you sound like less of an authority to be minded. Calley Means is right that the medical establishment is a stodgy place of often questionable effectiveness. Dr Anekwe and her colleagues appear to be willing to settle on this sort of low-evidence, "woke medicine" model of "It's genetics. It's not your fault", and if she doesn't really believe that, she bungled an opportunity to set the record straight. That said, she is correct about the primary measures of diet, movement, sleep and stress management. I'll give her that, I just wish she sounded more up-to-date with the studies. There are doctors that appear to stop learning out of med school, and there are doctors that are curious and write books on the leading edge of medical science and Anekwe seems like neither; she just doesn't totally appear to understand the literature. If we really think the primary cause of obesity is that we have somehow evolved a major genertic mutation in the last 50 years and that it's nothing to do with changes in diet—all of a sudden?—we're in real trouble with the state of evidence-based medicine. Dr Prasad and Means are correct here: people haven't changed, but the food production, incentives and cultural norms have.

3. Dr. Vinay Prasad (now I know how to pronounce his first name—thank you) is somebody I follow on the 'Stacks and who I rate highly, and his opinions fell where I would hope they would, in the sensible middle, with nuanced understanding. While not a doctor directly involved in obesity, he was a good voice to have on for his strict attitudes to following the data, something we see less of. I largely agree with his few interjections about Calley's weaking his own argument, and appreciated his input.

4. Bari did a good job pushing back where necessary, and this is why I pay money for the Free Press. But she came off as inadequately sussed when she framed the only two scenarios on offer, which were essentially "Will power and personal responsibility", a framing designed to make people make a frowny face, and "taking a pill", which most people should be skeptical of, yet will be beguiled by. The former is a kind of "conservative" straw man which takes attention away from focus on the lack of education OF and BY our health authorities and the discipline required by ordinary people to swim against the tide of our cultural, post-industrial food economy where corn and sugar are subsidized to such a degree. This common idea of what we are told by health authorities we ought to be doing, and what a big downer it all is to the average person—you see it in our advertising, movies and TV shows—is a cultural trope that people who pursue fitness largely become less susceptible to. On the one hand, it makes Bari someone readers and listeners can relate to. On the other, it somewhat detracts from furthering the conversation, as it can't escape its "normie" moorings.

Getting obesity to drop purely on account of lifestyle and dietary interventions IS the correct goal, but it is also a wicked problem on the level of solving problems brought on by a changing climate, because you have to change everybody's mind, and you aren't going to be able to.

If it is the excuse by Drs Stanford and Anekwe to effectively "give up" on pursuing true health for unhealthy patients for the easy road of pharmacological interventions and ignorance, I would say they aren't trying hard enough, or are not able or competent enough to marshal the courage and resources to make more of an impact. I fear for a medical establishment that doubles down on its own feeling of fecklessness and inefficacy, and that is how Anekwe's clinic came off in this debate.

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I enjoyed the conversation, and I’m currently training in Preventive Medicine and Public Health (the same specialty as Dr. Anekwe), though I don’t practice obesity medicine in as specialized of a manner. The ACGME (which oversees all physician training) has added some significant mandates for us on lifestyle medicine; we are required to provide educational programming for our residents on lifestyle, including diet, exercise, and stress management. We tried to get a major curriculum for the other medical specialties in our system, but haven’t been successful as yet. Most physicians know less about nutrition than I do, and I don’t know an enormous amount. So I agree that the educational piece is not adequate and change is happening quite slowly, but there is a broad impetus in the profession to learn more about diet.

I interviewed for a position with one of the country’s leading medical centers for lifestyle and the junior physicians working there had an interesting perspective: they didn’t think doing extra training to get certified in lifestyle medicine was valuable, because the structural factors influencing lifestyle overwhelmed individual choice (which concurs with Dr. Prasad’s opinions on built environments and Calley’s overall thrust about the food system).

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I was really disappointed that Bari didn’t push the panel harder on how to implement diet/exercise solutions in the real world. As a working mom, I’m doing my best to get my kids ready and out the door to school and I don’t have time to make breakfast from scratch. The end of the day struggle is just as bad when I’m rushing to make dinner for a hungry family. While everyone was nostalgic for the 60s and 70s, most of the parents who make the meals these days also work full time and don’t have an entire afternoon to make healthy from scratch. I left very disappointed with the entire panel for making me feel like I’m part of the problem but without offering any solution. All the public health messaging in the world isn’t going to get me the time and energy I need to make non-processed meals.

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I agreed with Calley on many of his substantive points but his insufferable smug demeanor made me not want to agree with anything he said. He needs to tone it down a bit and not be so constantly outraged in a room with adults.

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I think it was Vinay who advocated for a strong public health campaign, citing evidence that the campaigns have worked in the past (e.g., smoking, vaccines) and suggesting that the public trusts public health officials. That may have been true in the past, but those days are gone after COVID. Trust in public health officials is at an all-time low!

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I find it a little frustrating when people complain about the problems and distorted incentives created by the political process. And then say that the solution is to use the political process to improve public policy. If it didn’t work the first time, it's not going to work the second time. All three participants seemed to do this.

In my opinion, change is going to occur in the cultural sphere, from the bottom up. It’s going to be families, friends, communities around podcasts like this one, and innovators in the private sector who objectively look at the evidence, question the mainstream guidelines, and take different steps to actually improve their health. It won't be easy given those distorted incentives, but I wouldn't hold my breathe while we wait for policymakers to solve this. Any changes to occur at the level of public policy or large public health institutions are going to be lagging indicators.

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As someone who has been working in the obesity research space, as well as being someone who has always struggled with my weight since childhood. I strongly think this is an avenue of research we need to continue to learn about.

I've been the girl who could only remain thin if I exercised 7 days a week and kept my calories low (abnormally low). I would gain weight when I looked at carbs the wrong way and it's always been incredibly frustrating. Things got much more challenging when I added Depo shots to the mix. I've always believed it had to be more than just input and output. We are finally in a space that supports this idea. Clearly insulin and hormones play a really big roll in weight loss and I welcome the use of these drugs to help aid in the weight loss struggle. If it truly was as simple as move more eat less, then we'd have far less obese people all over the world.

We can work on all aspects of the spectrum. Improve food in the US, remove the push on sugar and processed food. Encourage kids early to get out more, make it easier to access forms as exercise for all ages. As well as incorporate medical intervention for those who need it. These drugs for someone like myself, give me absolute hope that there is something we can add to our regimes that actually works.

The patient population I see does experience significant side effects. Usually gastric (nausea, vomiting, constipation, diarrhea, GERD etc) as well as fatigue. However, these symptoms seem to only last as long as dose increases and can be managed. As far a weight increase after discontinued dose, we need to continue those studies.

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